Male Menopause: Reality or Myth?

For women of a certain age, menopause is a fact of life. But
this middle-age change no longer looks so feminine.

More men are arriving in doctors' offices complaining of
sexual dysfunction, weight gain, fatigue, depression and other unpleasant, but
potentially vague, symptoms. In some of these men, a blood test reveals low
testosterone levels. And there has been a corresponding uptick in testosterone
prescriptions, one approach to treating low male hormone levels.

For these patients, doctors like Robert Brannigan in Chicago
may give testosterone replacement a trial run to treat symptoms which, he said,
can have a profound effect on a patient.

"It helps many, many of these individuals to have
overall improved quality of life. It not only affects them, but very
often their partners and their intimate relationships," said Brannigan,
an attending physician at Northwestern Memorial Hospital and an associate
professor of urology at the Northwestern University Feinberg School of
Medicine.

Male menopause, as it has been dubbed, is controversial.
First there's the name, which experts dislike because it draws an inaccurate
parallel with the female experience. (The accurate term for men is late-onset
hygonadism.) What's more, the disorder itself is not universally accepted, with
some saying there is weak evidence for a link between symptoms and decreased hormone
levels, and questioning whether benefits outweigh the risk and unknowns of testosterone
prescriptions.

"I think the question that arises is how much of this
is related to hormones and how much of it is the facts of life that we
experience as we age," said Dr. Thomas Walsh, an assistant professor and
director of male reproductive and sexual medicine at the University of Washington's
School of Medicine in Seattle. Walsh, a urologist, prescribes testosterone after
what he describes as "heavy informed consent."
[7
Ways the Mind and Body Change With Age]

"There is still a lot of controversy, and I don't think
we have all the answers yet. You have to take the data at hand and apply it to
the individual," he said.

Up to four million men may have low testosterone, with most caused by age-related declines. However, only a minority receive treatment, according to Walsh. That number of
men affected is expected to rise.

The female misnomer

'Male menopause' may grab attention, but experts dislike the
term, because it glosses over the significant differences between the hormonal
changes men and women experience as they age.

"Nobody doubts female
menopause, and nobody doubts the mechanism by which it happens, that's not
the case for male menopause," said Dr. Ike Iheanacho, editor of the
journal Drug and Therapeutics Bulletin, which in June published a review on
using testosterone to treat so-called male menopause. "That epithet is
unhelpful, because it deters people from doing what we [have] done, which is
look at the evidence."

The review, which reflected the journal's opinion, found
weak causal evidence that age-related hormone declines cause symptoms in men, a
lack of long-term data, and at best, mixed results for short-term treatment.

For a woman, menopause marks the end of fertility and occurs
when progesterone and estrogen, produced by the ovaries, drop off. Symptoms can
last several years, according to the U.S. National Institutes of Health (NIH).
Hormonal changes in men are quite different. Testosterone
levels can decrease by about 1 percent to 2 percent each year after about
the age of 40. While menopause is a universal experience for women,
testosterone does not decline in all men. Other factors besides aging, like
obesity or injury, are associated with low testosterone.

For many years, long-term hormone replacement for women was
considered protective for all kinds of ailments, until study results in 2002
revealed it increased risks of heart disease, stroke, blood clots and breast
cancer, according to the NIH.

This history has implications for men with low hormones and
symptoms, Walsh said. "You are seeing today far more caution on the part
of clinicians and investigators."

Questions

Two papers published in the July issue of the New England
Journal of Medicine addressed the diagnosis of hypogonadism and its treatment.

In one study, researchers led by Frederick Wu of the
University of Manchester used data from 3,369 European men to find correlations
between testosterone levels and a battery of potential symptoms. As a result,
they suggested that the presence of at least three measures of sexual
dysfunction, including frequency of thoughts about sex and erectile function, in
a man with a testosterone level below 11 nanomoles per liter could be used to
define late-onset hypogonadism. (The study defined a decreased level as between
13 and 8 nanomoles per liter for total testosterone.) However, these symptoms
were also widely reported by men who did not suffer from depressed hormone
levels.

This causal relationship between hormone levels and symptoms
is always a question, according to Dr. William Bremner,
chairman of the department of medicine at the University of Washington's School
of Medicine, who wrote about that research in an editorial in the journal.

"In truth you don't know that those are due to the testosterone
until you give men testosterone and see whether those symptoms are
improved," he said.

Testosterone has been shown to increase muscle mass and
strength, so a second study in the same journal issue set out to test how much
testosterone supplementation was needed to increase mobility among men ages 65
or older with difficulty walking or climbing stairs. The authors, led by
Shehzad Basaria of Boston University's School of Medicine and Boston Medical
Center, found evidence that testosterone did improve the men's strength. However,
the men taking testosterone also experienced an unusually high rate of
cardiovascular problems.

The latter result is surprising, and may be due to chance, since
previous studies have not shown a connection between testosterone and
cardiovascular risk, Bremner said.

The Women's Health Initiative Study, which revealed risks of
hormone replacement therapy, followed a total of 161,808 women over 15 years.
No long-term research like this has been conducted in men, but it is needed, Bremner
said.

"There really are a large number of older men receiving
testosterone and the numbers seem to be increasing and it's not something that
is going away," he added.

On the rise

In roughly the past four years, Brannigan's urology practice
has seen an increase in patients he said are suffering from late-onset
hypogonadism.

"Certainly, there is no question we are seeing more
patients, and the question is, and I don't think we know, is it due to
increased public awareness or is it due to increased prevalence,"
Brannigan said. Still, he estimates that 95 percent of cases are undiagnosed.

His office is not unique. With an aging, more at-risk
population living in a post-Viagra era, when taboos on men's sexual health
issues like
erectile dysfunction are lifting, the increase is expected to continue. Prescriptions
appear headed up as well.

Between 2005 and 2009, testosterone prescriptions dispensed
by pharmacies rose 65 percent in the United States, according to a LiveScience
analysis of data from IMS Health, a heath-care information and consulting
company.

There is also a lifestyle connection. Low testosterone is
associated with obesity, diabetes and metabolic syndrome – a combination of
disorders linked to diabetes and cardiovascular disease. All three are on the
rise within the United States, according to data from the Centers for Disease
Control.

Wynne was a reporter at The Stamford Advocate. She has interned at Discover magazine and has freelanced for The New York Times and Scientific American's web site. She has a masters in journalism from Columbia University and a bachelor's degree in biology from the University of Utah.